Director Robert Redfield, head of the Centers for Disease Control and Prevention (CDC) visited Maricopa County, Arizona Wednesday, July 18 to discuss strategies to end the HIV epidemic, which has hit the state’s most populous county particularly hard. President Trump has called for $291 million in Fiscal Year 2020 to implement Ending the HIV Epidemic: A Plan for America, the Department of Health and Human Services’ plan to reduce new HIV infections by 90% in ten years. If funded, this concentrated effort will represent a significant step toward the goal of ending the epidemic, a goal the United States has the medical capacity to achieve. Despite the continued existence in some states of HIV criminalization laws, including some that criminalize behavior that cannot transmit the disease, the plan also signals a shift away from stigmatization of the disease and people who live with it.
The proposed plan will have a particular focus on Maricopa County because it is one of 50 jurisdictions in the United States that a recent CDC analysis of HIV data found to account for over 50% of the country’s new HIV diagnoses in 2016 and 2017. The proposed plan will initially target resources to these 50 jurisdictions and seven states with a significant rural HIV burden. Additionally, Maricopa County had the lowest rate of adults who had ever been tested for HIV among these jurisdictions. That rate, 36.5%, is just over half the rate of the jurisdiction with the highest rate, Washington, DC, where 70.7% of adults have been tested. While HIV testing is available at several clinics and other locations across Maricopa County, the cost at many locations is prohibitive, and a concerted effort to make testing more accessible is needed to allow more Maricopa residents to know their status and access treatment as needed.
The proposed plan also focuses on expanding access to treatment medication for those diagnosed with HIV and prevention medication for those at highest-risk of contracting it, particularly black and Latinx gay and bisexual men and people who inject drugs. Both types of medication are extremely effective if taken as prescribed. The treatment medication, antiretroviral therapy (ART), lowers the viral load in the body to prevent illness and is itself considered a preventative measure because if the load is lowered to an undetectable level, it becomes untransmittable to another person. The prevention medication, known as pre-exposure prophylaxis (PrEP), reduces the risk of contracting HIV through sex by 99% and through injection drug use by 74% if taken daily.
Director Redfield praised Arizona for taking an important step to make PrEP more accessible to residents. Currently, insurers that require prior authorization for certain medications, such as PrEP, must approve those medications before a health care provider can prescribe them even after that provider has determined it represents the best option for the patient. This process can lead to unnecessary and sometimes detrimental delays in accessing the treatment patients need, and it is estimated to cost HIV clinics over $40 per prior authorization request. Starting in October though under a new state policy, health care providers will be able to prescribe PrEP to patients covered by the Arizona Health Care Cost Containment Program, the state’s Medicaid program, without prior authorization.
Despite Arizona’s new policy to prevent such delays, the state legislature has failed two years in a row to deliver another important piece of the prevention puzzle, syringe services programs. The proposed national plan advocates for the use of such programs given their proven efficacy to prevent HIV and other infectious diseases, but many states still oppose them, and the Arizona legislature adjourned the 2018 and 2019 sessions without voting on bills introduced to establish them.
The proposed national plan and state and local efforts to end the HIV epidemic in America represent significant progress toward combating the disease. Despite this progress, it is clear that testing, prevention, and treatment remain inaccessible to those most at risk. If the United States is to ever reach this goal of effectively ending the epidemic, it must focus its efforts on making resources truly accessible to the most at-risk populations.
Photo courtesy of the Secretary’s Minority AIDS Initiative Fund
The views reflected in this expert column are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.